Emergency medicine: What is it exactly today?

I’m not old enough, in emergency medicine years, to identify with the struggle of those calling for the end of the term “ER.” The argument was about the “R” vs. the “D”: “It’s not a room!” It’s a department!” was the war cry. Then perceptions changed, battles were won, and along came the very popular TV show, “ER.” The war hawks quieted down. After all, who could argue with the limelight into which our profession was cast? Now a new battle is underway. This fight is not about credibility or legitimacy, but sustainability and identity. It’s about the “E.”

The “E” can no longer stand for “emergency” at least in a literal sense. Only a minority of time and resource are used to take care of emergencies. Rather, the “E” should now stand for everything. Instead of the classic “emergency room” we now have an “everything department.” We can care for your poison ivy or your pulmonary embolism, your chronic migraine headache or your acute myocardial infarction, and most things in between. We can be a one-stop shopping department for a lot of folks, and to paraphrase Jeff Spicoli (Fast Times at Ridgemont High, 1982), we’ve got an awesome set of tools, we can fix it! The “room for emergencies” has indeed become a “department for everything.”

Going further, the”E” isn’t just everything; it’s everyone. We don’t turn anyone away and consequently, the ER should now be the “Everything, for Everyone, Department.” The government gets a lot of the credit for this via EMTALA. No insurance? No problem. No ID or passport? No problem. Many folks have no alternative source of timely care, true, and providers and administrators alike don’t really want to turn away business – I mean patients. Bring in the poorly managed chronically ill, the low acuity, the work note shoppers, the convenient care seekers, as well as the emergencies. We’ll take them all.

And, of course, “E” could also stand for every time. After all, we’re never closed either; “The Everything, for Everyone, Every time Department.” We’ve always been open nights, weekends, and holidays, as most homes are. Though tempted at times, we don’t close the doors at 5:00 or midnight or on Christmas day. Perhaps we should have a little more “tough love” philosophy in our medical home.

Are emergency departments, as part of the power struggles between hospitals, in remodeling their facilities, concentrating on patient satisfaction, and offering an increasing array of services, crowding out other, more appropriate, venues of care? Are these other venues really stepping up to help cure the problems in American health care delivery? Are people being pushed into the ED or being pulled into the ED? Does anyone have any idea of where the emergency department, in today’s health care market, fits in? If so, are those people willing to put their money where their mouth is? Are they willing to pay for it? Are we, the emergency medicine community, here entirely by default, necessity, or perhaps by a bit of covert advertised-wait-times marketing?

Emergency medicine, it seems to me, has a serious identity crisis. Are we emergency specialists or everything generalists? Which do we want to be and perhaps, more importantly, which will we be required to be? How will we train our residents? Should we be teaching more primary care? What should we be taking care of? Who should we be taking care of? When should we be taking care of them?

Though the answers to these questions are important, it’s more important to determine who will be answering them; politicians, executives, lobbyists, or physicians – particularly emergency physicians? This is a systems problem. We need a unified, clear, common sense answer to the question of “what is emergency medicine?” from emergency physicians.

I’m curious to see where we’ll be in 25 years, particularly with health care reform on the verge of causing some seismic shifts in at least financing, if not delivery. Perhaps, the system will push us out of the department and back into a room. Or perhaps, in the vernacular of our surgical colleagues and considering the growing focus on customer satisfaction, we’ll now start to call it the “Emergency Suite” (and, by the way, that’s a nice flat screen HDTV in room 23). And who would argue, with the usual cast of characters and dramatic moments that at times we seem to be practicing in an “Emergency Theater”? Surely, we haven’t become the “Everything, for Everyone, Every Time Department with Suites and a Theater.”

Emergency medicine: What is it exactly today? 10 comments

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Former “emergency” physician

This is an interesting post in that it echoes the prescient rumblings of many physicians in the ED trenches. I worked for years in a suburban
ED and an urban high acuity teaching hospital ED. What was common in both settings over recent years was an ever increasing shifting of resources towards the care of ambulatory patients due to the simple fact that the ED directors and their bosses viewed such patients as the most important customer group. These patients were viewed as maximizers of RVUs per hour (in the setting of 3rd party insurance) and were also potential recipients of Press Ganey surveys. ED directors often seemed to have limited interest in the management of critically ill or admitted patients in the ED beyond meeting CMS & JCAHO metrics and keeping boarding times under control. Even as we called ourselves emergency physicians and trained our residents in resuscitation and the evaluation/ management of potentially deadly or disabling conditions, it often seemed oddly out of step with the job these residents would be asked to perform in community EDs across the US. As it became clear that further ED resources were unlikely to be devoted to the care of emergently ill patients unless there was a compelling CMS or JCAHO metric, I watched befuddled as my ED directors and colleagues embraced the new order of convenience clinic and admission triage.

The irony is that by redefining our role (or having our role externally redefined) in this regard we are assuring radical changes in the practice of “emergency” medicine. There will be a need to not only scale back somewhat the current emphasis on potentially deadly or disabling conditions in resident curricula, but also an attendant focus on ambulatory care within a convenience clinic model will be needed. However, more radically, the role of “emergency” physicians in the “emergency” department will also need a structural overhaul. Some physician executives and institutional administrators have already begun to realize that the current EP training model produces workers who are overskilled
and overeducated for the job they will be increasingly focused on performing in the future. The only limiting factor will be the ability of institutions to recruit and retain midlevel providers of sufficient quality. I can imagine a future in which “emergency” physicians are left with providing single coverage during off peak hours, primarily seeing more complex patients, and providing assistance/assuming joint liability when consulted by midlevel colleagues.

Myles Riner, MD

Try Googling ED or E.D., then Google ER. Unless you’re looking for Viagra, ER is,and remains, the place to go for emergency care.

marykparker

I love your tagline for the modern-day Emergency Department—your marketing department should thank you for developing a clear and concise definition of what today’s “Everything, for Everyone, Everytime Department” looks like!

ismaelantonio

Excellent article. As a philosophy student, it seems to me that the ER or ED has become the battleground or discussion forum (which ever you prefer) for ethical dilemas concerning health that had been unatended before. Just as you stated it, the purpose of the ER is unclear nowadays, and I think it’s a result of the changes made in Health Care by government and Courts – which do not always go along – and the misinterpretation of them by the common people, hospitals and physicians themselves (EMTALA as an example).

Fantastic post! Every shift, it seems I’m called upon to manage more chronic problems, more complex disease, more impossible social solutions than ever before. And the groups, or organizations, or specialists who should do so are unavailable for financial reasons, or their offices are full, or their schedule is limited or they just don’t want to do it. Add to that the endless parade of criminals brought for ‘evaluation’ rather than incarcerated, the constant drug-seeking, the crushing regulatory burden, truckloads of forms and non-stop demands of administrators and you have a completely unmanageable situation.
Well spoken doctor!

buzzkillerjsmith

ER: tough gig. Burnout almost assured. As part of a vanishing breed, primary care, I’m sorry to say you all will have to pick up the slack. Are you the one’s who are going to hold even more of the bag? Will students get the message that a combo emergency expert and bag-holder is too much? The blight of administation, will that reality filter down? Time will tell.
I sincerely wish you all good luck and am happy you’re fighting the good fight.

buzzkillerjsmith

ones not one’s.

southerndoc1

Primary care is dead; general surgery has one foot in the grave; will ER medicine be the next to fall? Well, at least we know we’ll all have beautiful, wrinkle-free skin.

John

Our college should focus on preparing it’s members to do something else after about 10 years. I’m glad I only do it PT now.

Very good article. As usual triage is key here and staffing. Many examples of division of the ER into urgent care and acute care. With the advent of hospitalist admission teams flow and door to doctor or midlevel time I think has improved but I’m sure there are many variables to that as well. The machines are out there and a good ER is essential to a hospitals.